ROTH IRA DISTRIBUTION REQUEST

Please read the attached instructions.

1 Transfers between brokers must include Letter of Acceptance from the receiving Custodian.

ACCOUNT HOLDER’S INFORMATION (Complete all sections)

Full Legal Name

Account No.

SSN/ITIN/Tax ID (Required by the IRS)

Date of Birth (Optional)

BENEFICIARY (OR FORMER SPOUSE) INFORMATION (Complete all sections) This section should only be completed by a beneficiary taking a death withdrawal or transferring inherited IRA assets to another IRA, or by a former spouse taking a withdrawal as a result of a court-approved property settlement due to divorce or legal separation.

Full Legal Name

Account No.

SSN/ITIN/Tax ID (Required by the IRS)

Date of Birth (Optional)

Relationship

TYPE OF DISTRIBUTION (Select one. Note: Transfer of Assets Between Brokers must include a Letter of Acceptance from the receiving Custodian)

Qualified (ROTH IRA greater than 5 years old, age 59 ½ and older, Death or Disability if ROTH IRA is greater than 5 years old)

Premature (Under age 59 ½)

Transfer to Identical Roth IRA1

(Select one if applicable)

Transfer of Assets Between Brokers

Roth Distribution with Exception Transfer to Beneficiary IRA (Or Spouse’s IRA if applicable)

Transfer Incident to Divorce

Excess Contribution Removed Before Excess Removal Deadline & Recharacterications The Gross Distribution amount must include the Net Income Attributable (NIA). The calculation method for NIA is found in IRA Pub. 590-A on Worksheet 1-3. Please note that the Net Income Attributable (NIA) cannot be left blank. The Gross Distribution entered in ‘Section IV. Distribution Method’ should equal the Gross Distribution amount in this section.

Excess Contribution Removal Before Excess Removal Deadline

DATE EXCESS CONTRIBUTION WAS MADE (If multiple contributions were made, then date of first excess contribution)

CALCULATE THE GROSS DISTRIBUTION

Excess Contribution Amount $_______________ + or – Net Income Attributable (NIA) $_______________= Gross Distribution $_______________

Same Year (Completed the same year as the year for which the contribution(s) was made)

Prior Year (Completed in the year following the year for which the contribution(s) was made)

Recharacterization

CALCULATE THE GROSS DISTRIBUTION

Contribution or Conversion Amount $_______________ + or – Net Income Attributable (NIA) $_______________ = Gross Distribution $_______________

Same Year (Completed the same year as the year for which the contribution(s) was made)

Prior Year (Completed in the year following the year for which the contribution(s) was made)

Excess Contribution Removed After Excess Removal Deadline (Remove only amount of true excess without NIA)

Death Withdrawal from a Beneficiary IRA

Disability (Within the meaning of Section 72(m)(7) of the Internal Revenue Code)

Revocation (Taken within 7 calendar days from the date account was opened)

Prohibited Transaction (A prohibited transaction is a transaction between a plan and a disqualified person that is prohibited by law)

PF10074-UDST 02/19/2019

ROTH IRA DISTRIBUTION REQUESTDISTRIBUTION METHOD (Select one distribution method. Excess Removal or Recharacterizations enter Gross Distribution amount from Section III)

One Time Distribution

PAYMENT IN THE AMOUNT OF $

DISTRIBUTION OF SECURITIES (Indicate Symbol/Cusip & Quantities)

SYMBOL/CUSIP QUANTITY SYMBOL/CUSIP QUANTITY

1 3

2 4

Scheduled Distribution (Complete all applicable items)

SELECT ONE New Request Change of Instruction

FREQUENCY (Select One) Bi-Weekly Weekly Monthly Quarterly Annually

BEGINNING DATE

AMOUNT $ OR Dividends & Interest (ACH Only)

Total Account Distribution (Account will be closed)

TAX WITHHOLDING ELECTIONS (Select applicable items. Do not complete this section for a transfer, recharacterization, or if you are a non-resident alien)

Federal Income Tax Withholding (Select One)

Do NOT withhold Federal Income Tax (By selecting this, the account holder understands that they are still liable for the payment of Federal Income Tax on the amount of any distributions received. The account holder also understands that they may be subject to Federal Income Tax penalties under the estimated tax payment rules if their payments of the estimated tax and withholdings are insufficient)

Withhold % from the account of the Gross Distribution (Must be at least 10%)

Withhold $ of Federal Income Tax from the Gross Distribution Amount (Must be equal to or greater than 10%)

State Income Tax Withholding (Select One)

Do NOT withhold State Income Tax from the Distribution (Not applicable to all states)

Withhold % from the account of the Gross Distribution

Withhold $ of State Income Tax from the Gross Distribution Amount

DELIVERY INSTRUCTIONS (Select applicable items)

Address of Record

Alternate Payee or Alternate Address (Notary Public/Signature Guarantee required if check is made payable to alternative payee)

NAME

ADDRESS CITY STATE ZIP CODE

To the following Apex Account ACCOUNT NO.

Special Payment Instructions INSTRUCTIONS

Overnight Delivery (Fees will be assessed)

Federal Fund Wire (Fees will be assessed)

ABA NO. ACCOUNT NO. BANK NAME

ADDRESS CITY STATE ZIP CODE

FOR CREDIT TO TYPE OF IRA ACCOUNT RECEIVING

BENEFICIARY ACCOUNT NO. FURTHER CREDIT TO

PF10074-UDST 02/19/2019

ROTH IRA DISTRIBUTION REQUEST

NOTICE OF WITHHOLDING The distributions you receive from your individual retirement account established at this institution are subject to Federal income tax withholding unless you elect not to have withholding apply. You may elect not to have withholding apply to your distribution payments by completing the "Tax Withholding Election" section on page 3 of this form. If you do not complete the "Tax Withholding Election" section by the date your distribution is scheduled to begin, Federal income tax will be withheld from the amount withdrawn at a rate of 10%. If you elect not to have withholding apply to your distribution payments, or if you do not have enough Federal income tax withheld from your distribution, you may be responsible for payment of estimated tax. You may incur penalties under the estimated tax rules if your withholding and estimated tax payments are not sufficient. SIGNATURE (This request cannot be processed without account holder’s signature)

ROTH IRA Holder or Beneficiary Signature Date

I certify that I am the proper party to receive payment(s) from this ROTH IRA and that all information provided by me is true and accurate. I have read and understand the Reporting Information Applicable to Withdrawal on page 6 of this form and agree to abide by those rules and conditions therein. I further certify that no tax advice has been given to me by the Trustee or Custodian. All decisions regarding this withdrawal are my own. I expressly assume the responsibility for any adverse consequences which may arise from this withdrawal and I agree that the Trustee or Custodian shall in no way be held responsible.

NOTARY (Public/Signature Guarantee) Notary Seal:

Notary Signature

FOR INTERNAL USE ONLY

Registered Principal Approval:

Print Name Title Signature Date Compliance Officer Approval/Registered Principal Approval:

Print Name Title Signature Date

PF10074-UDST 02/19/2019

ROTH IRA DISTRIBUTION REQUEST

REPORTING INFORMATION APPLICABLE TO ROTH IRA WITHDRAWALS

You must supply all requested information for the withdrawal so the trustee or custodian can properly report the withdrawal.

If you have any questions regarding a withdrawal, please consult a competent tax professional or refer to IRS Publication 590-B, Distributions from Individual Retirement Arrangements (IRAs), for more information. This publication is available on the IRS website at www.irs.gov or by calling 1-800-TAX-FORM. WITHDRAWAL INFORMATION

Roth IRA assets can be withdrawn at any time. Most Roth IRA withdrawals are reported to the IRS. IRS rules specify the distribution code that must be used to report each withdrawal on IRS Form 1099-R, Distributions From Pensions, Annuities, Retirement or Profit-Sharing Plans, IRAs, Insurance Contracts, etc.

Five-Year Period. You have satisfied the five-year period for determining qualified withdrawals on January 1 of the fifth year following the year for which you made your first Roth IRA contribution, conversion, or rollover from an eligible employer-sponsored retirement plan.

Qualified Withdrawal. A qualified withdrawal is one where you have satisfied the five-year waiting period and the withdrawal is due to being age 59½ or older, death, or disability. Qualified withdrawals are reported on Form 1099-R using code Q.

WITHDRAWAL REASON

Transfer to Another Roth IRA. Transfers are not reported on Form 1099-R. Transfers may be made by a Roth IRA owner, beneficiary, or former spouse under a transfer due to a divorce. Inherited IRA assets may only be transferred to another inherited IRA, unless you are a spouse beneficiary.

Age 59½ or Older. If you are age 59½ or older, withdrawals are reported on Form 1099-R using code T, unless they are qualified withdrawals.

Under Age 59½. If you are under age 59½, withdrawals for any reason not listed above are reported on Form 1099-R using code J.

• Disability. If you are under age 59½ and disabled, withdrawals are reported on Form 1099-R using code T, unless they are qualified withdrawals.

• IRS Levy or Substantially Equal Periodic Payments. If you are under age 59½, withdrawals due to IRS levy or substantially equal periodic payments are reported on Form 1099-R using code 2.

Death Withdrawal by a Beneficiary. Withdrawals by beneficiaries following the death of the original Roth IRA owner are reported on Form 1099-R using code T, unless they are qualified withdrawals.

Prohibited Transaction. Prohibited transactions as defined in Internal Revenue Code Section 4975(c) are reported on Form 1099-R using code 5.

Excess Contribution Removed Before the Excess Removal Deadline. Excess contributions removed before the excess removal deadline (your tax filing deadline, including extensions) must include the net income attributable to the excess.

• If your excess contribution was contributed and removed in the same year, before the excess removal deadline, the withdrawal is reported on Form 1099-R using codes 8 and J.

• If your excess contribution was contributed in one year and removed in the next year, before the excess removal deadline, the withdrawal is reported on Form 1099-R using codes P and J.

Excess Contribution Removed After the Excess Removal Deadline. If your excess contribution is removed after the excess removal deadline, the withdrawal is reported on Form 1099-R using code J if you are under age 59½, code T if you are age 59½ or older, or code Q if the distribution is a qualified withdrawal.

Recharacterization. A Roth IRA contribution including the net income attributable may be recharacterized as a Traditional IRA contribution up until your tax filing deadline, including extensions. Recharacterizations also may be used to reverse Traditional IRA or SIMPLE IRA conversions to Roth IRAs.

• Recharacterizations that occur in the same year for which the contribution was made are reported on Form 1099-R using code N.

• Recharacterizations that occur after the year for which the contribution was made are reported on Form 1099-R using code R.

Revocations. Revocations of regular contributions, conversions, rollovers, or transfers are reported on Form 1099-R using code J. A revocation of a regular contribution with earnings if you are under age 59½ is reported on Form 1099-R using codes J and 8.

PF10074-UDST 02/19/2019